Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Type of Referral, Dialysis Start and Choice of Renal Replacement Therapy Modality in an International Integrated Care Setting

Type of Referral, Dialysis Start and Choice of Renal Replacement Therapy Modality in an International Integrated Care Setting

  • Belén Marrón, 
  • Janusz Ostrowski, 
  • Marietta Török, 
  • Delia Timofte, 
  • Attila Orosz, 
  • Andrzej Kosicki, 
  • Alicja Całka, 
  • Daniela Moro, 
  • Dezider Kosa, 
  • Jenö Redl
PLOS
x

Abstract

Introduction

Integrated Care Settings (ICS) provide a holistic approach to the transition from chronic kidney disease into renal replacement therapy (RRT), offering at least both types of dialysis.

Objectives

To analyze which factors determine type of referral, modality provision and dialysis start on final RRT in ICS clinics.

Methods

Retrospective analysis of 626 patients starting dialysis in 25 ICS clinics in Poland, Hungary and Romania during 2012. Scheduled initiation of dialysis with a permanent access was considered as planned RRT start.

Results

Modality information (80% of patients) and renal education (87%) were more frequent (p<0.001) in Planned (P) than in Non-Planned (NP) start. Median time from information to dialysis start was 2 months. 89% of patients started on hemodialysis, 49% were referred late to ICS (<3 months from referral to RRT) and 58% were NP start. Late referral, non-vascular renal etiology, worse clinical status, shorter time from information to RRT and less peritoneal dialysis (PD) were associated with NP start (p<0.05). In multivariate logistic regression analysis, P start (p≤0.05) was associated with early referral, eGFR >8.2 ml/min, >2 months between information and RRT initiation and with vascular etiology after adjustment for age and gender. “Optimal care,” defined as ICS follow-up >12 months plus modality information and P start, occurred in 23%.

Conclusions

Despite the high rate of late referrals, information and education were widely provided. However, NP start was high and related to late referral and may explain the low frequency of PD.

Introduction

The prevalence of chronic kidney disease (CKD) defined as eGFR <60 ml/min/1.73 m2 has reached epidemic proportions, with studies showing a prevalence of 10–13% [13]. Indeed, CKD is recognized as a growing global public health problem due to the rising rates of diabetes mellitus, obesity, hypertension and aging populations [46]. The cost associated with renal replacement therapy (RRT) [dialysis or kidney transplantation] needed by these patients (roughly 0.1% of the general population), comprises 1–2.5% of the total health care spending in high-income countries [7]. The variation in RRT incidence across countries is thought to be associated with countries’ economics, health care system and renal service factors rather than population demographics and health status [78].

Some traditional hemodialysis (HD) providers have recently developed ICS clinics aiming to increase quality of life and life span for patients as well as to diminish costs through a more sustainable renal care model [910]. ICS offers a holistic renal care approach to patients in the transition from early CKD care into RRT, offering at least both types of dialysis (HD and PD). These ICS clinics usually offer a multidisciplinary team approach, including dietitians, psychologists and social workers, and providing information, education and support to revitalize these patients in all functional areas [11]. ICS may increase efficiency of CKD care by promoting timely and adequate channels for patient referral to nephrologists, contributing to a planned dialysis start and offering balanced high quality RRT modality information as well as education [1112]. In order to diminish the gap between reality and the desirable care needed, several pitfalls should be addressed: inadequate medical training, timely referral to nephrologists, inappropriate patient information and education for RRT modality choice, lack of specialized predialysis programs and lack of planned RRT initiation [13].

In addition, PD remains underused despite having demonstrated to be at least equal to HD as the first dialysis modality, especially while there is residual renal function [1317]. Specialized predialysis programs have consistently demonstrated important benefits such as delayed progression of renal insufficiency, improved patient outcomes, decreased hospitalizations and urgent dialysis initiation need, as well as increased patient participation in modality choice and thereby increased use of home therapies [1825]. However, such infrastructures are not widely established and frequently insufficiently staffed [13,19,23,2629].

In the present study, we assess in a group of Eastern Europe ICS clinics which factors determine type of referral, modality provision and dialysis start on final RRT of a private renal services provider (Diaverum).

Materials and Methods

This is an international-multicenter observational retrospective study on the impact of ICS in all consecutive patients who started maintenance dialysis for CKD-5 from 1st January through 31st December 2012 in twenty-five ICS clinics in Poland, Hungary and Romania. Patients with pre-emptive transplants were excluded from the study.

Information was collected on demographic variables, cause of renal disease, follow up since diagnosis of kidney disease, medical specialist providing care, type of referral to ICS clinic [defined as early (ER) if ≥ 3 months and late (LR) if <3 months], predialysis care devoted by general nephrologist or by specialized predialysis staff (where at least a nephrologist and a nurse have been appointed part time into specific predialysis care), number of medical visits in the year prior to the start of dialysis, type of dialysis at first session and as ascribed chronic RRT, analytical parameters at dialysis start [24 h. urine creatinine clearance, estimated GFR (MDRD-4), serum creatinine, albumin, calcium and phosphorus, hemoglobin levels] and EPO prescription.

Information to patients on RRT modality (if provided) and general renal education (if delivered) were analyzed in a qualitative manner. Patients were assigned to the "modality informed" group when different RRT modalities were explained by staff, supportive information tools were used for this purpose (e.g. brochures, DVDs) or meetings with other patients in clinic facilities took place. Renal education was considered to be provided when patients were taught how to care for renal disorders and about the importance of compliance with prescriptions and follow-up visits. No single common protocol was created for this purpose. Each clinic designed the type and content of information taking into account local cultural issues.

The patient choice of dialysis modality, informed consent signing (for information and at dialysis start) and time elapsed from provision of information to dialysis start were also recorded.

RRT start was considered non-planned (NP) when either functional permanent access was lacking or an unscheduled (urgent) start occurred, even if a permanent dialysis access was in place. Optimal care was defined as patients followed-up in an ICS with more than 12 months receiving RRT modality information and having a planned dialysis start.

Ethics

This is a retrospective, non-interventional, observational cohort study with sourcing data obtained from routine practice in Diaverum clinics located in Romania, Hungary and Poland during 2012. The Study was approved by the Quality, Compliance and Data Protection Institution’s Commissioner. Patient records were anonymized and de-identified prior to analysis. Participant patients signed an informed consent form that included providing permission to record data for research and publication purposes in an anonymized manner.

Statistical Analysis

Data are expressed as median (10th to 90th percentile) or percentage, as appropriate. Statistical significance was set at the level of p <0.05. Comparisons between two groups were assessed with the nonparametric Wilcoxon test for continuous variables and a chi-square test for nominal variables. Differences among three or more groups were analyzed using the nonparametric ANOVA Kruskal–Wallis test. Spearman rank correlation analysis was used to determine associations between continuous and ordinal variables. Multivariate logistic regression analyses were used to assess determinants of P and ER vs. NP start, data was expressed as Odd ratios and 95% CI. The covariates were selected on the basis of biological plausibility. All statistical analyses were performed using statistical software SAS version 9.4 (SAS Campus Drive, Cary, NC, USA).

Results

A total of 626 patients started dialysis in 2012 but only 547 were evaluated after excluding patients returning from kidney transplantation (n = 23) and from one center with incomplete data (n = 56) (Fig 1). Patient classification according to type of referral and type of dialysis start was as follows: Group ER+P [168/547 (31%)]; Group ER+NP: [113/547 (21%)]; Group LR+P: [63/547 (11%)] and Group LR+NP: [203/547 (37%)]. Main clinical characteristics according to dialysis start planning are summarized in Table 1.

thumbnail
Fig 1. Patients Flowchart for clinical study evaluation.

Abbreviations: ER, early referred patients; LR, late referred patients; P, planned dialysis start patients; NP, non-planned dialysis start patients; ER+P, early referral and planned patients; ER+NP, early referral and non-planned patients; LR+P, late referral and planned patients; LR+NP, late referral and non-planned patients. A total of 626 patients started dialysis in 2012 from 25 Integrated Care Setting Clinics in Poland, Hungary and Romania at Diaverum Renal Services but only 547 were evaluated after excluding patients returning from a previous kidney transplantation (n = 23) and from one center with incomplete data (n = 56). Evaluated patients were primarily divided into two groups according with type of referral being 281 patients ascribed to the early referral and 266 patients into the late referral. Both groups were secondarily divided into another two groups each, depending on type of dialysis start. 168 patients were considered as early referred and with a planned dialysis start, 113 patients were considered as early referred but with a non-planned dialysis start, 63 patients were considered late referred but with planned dialysis start and 203 patients were late referred and had non-planned dialysis start. Planned dialysis patients were 231 of the total population and non-planned dialysis start were 316.

https://doi.org/10.1371/journal.pone.0155987.g001

thumbnail
Table 1. Clinical characteristics according to planning of dialysis start.

https://doi.org/10.1371/journal.pone.0155987.t001

Initial CKD care follow up, predialysis care and type of referral to ICS

The majority of the patients 459/547 (84%) were followed-up at initiation of CKD care by nephrologists (48%), general practitioners (12%) and other specialists (24%). Half (266/547) of the patients were referred late to ICS [in Romania (57%), Poland (50%) and Hungary (35%)]. Predialysis (GFR <30ml/min) care was provided in ICS more frequently by general nephrologists (68%) rather than by specialized predialysis staff (29%). Most patients 479/547 (87%) received some renal education prior to dialysis start. RRT modality information was provided to 436/547 (80%) of patients. Of the modality informed patients, final RRT was exclusively based upon patient´s choice in 57% of cases. The median time from information to dialysis start was 2 months. Patients (246/436; 57%) signed informed consents at the time of modality provision and at the time of dialysis start (421/547; 77%). More patients received modality information in the PD group (92%) compared with 78% in the HD (p = 0.02). Optimal care was observed in 123/547 (23%) of the patients.

Planned versus non-planned start

Reasons for becoming NP and needing urgent dialysis are presented in Table 2.

thumbnail
Table 2. Reasons for non-planned start and need of urgent dialysis start.

https://doi.org/10.1371/journal.pone.0155987.t002

316/547 (58%) started dialysis as NP and 113/316 (36%) of the NP patients were previously followed up, for at least 3 months, by nephrologists (54% of patients at an ICS clinic vs. 46% by referral nephrologists). Additionally, patients with NP start had worse clinical status at dialysis start and worse access management (Table 1 and Fig 2).

thumbnail
Fig 2. Type of dialysis access at first dialysis session accordingly with different studied subgroups.

Abbreviations: ER+P, early referral and planned patients; ER+NP, early referral and non-planned patients; LR+P, late referral and planned patients; LR+NP, late referral and non-planned patients. PD, peritoneal dialysis; HD, hemodialysis; AVF, arterio-venous fistula. Figure represents a diagram of bars showing the different types of accesses at first dialysis session. Accesses were as follows for the total population: 34.5% AVF, 8% peritoneal catheter, 8.5% temporal hemodialysis catheter and 49% permanent HD catheter. For ER+P: 77% AVF, 21% peritoneal catheter, no temporal hemodialysis catheter and 2% permanent HD catheter. For ER+NP: 0.8% AVF, 2.6% peritoneal catheter, 9% temporal hemodialysis catheter and 88% permanent HD catheter. For LR+P: 89% AVF, 8% peritoneal catheter, no temporal hemodialysis catheter and 3% permanent HD catheter. For LR+NP: 0.4% AVF, 1% peritoneal catheter, 18% temporal hemodialysis catheter and 80% a permanent HD catheter.

https://doi.org/10.1371/journal.pone.0155987.g002

Factors associated with P start were evaluated by a multivariate logistic regression analysis and are described in Table 3. Factors were adjusted for age and gender.

thumbnail
Table 3. Multivariate logistic regression for planned versus non-planned dialysis start.

Pseudo r2 = 0.26.

https://doi.org/10.1371/journal.pone.0155987.t003

More patients received education in the P (218/231, 94%) than in the NP group (218/316, 69%). At the time of modality information, P start patients had lower serum creatinine, longer predialysis follow-up and more patients were started on PD as RRT (p ≤0.01) (Table 4).

thumbnail
Table 4. Characteristics of patients with early referral (>3months) to Integrated Care Settings clinics follow-up according to planning of dialysis start.

https://doi.org/10.1371/journal.pone.0155987.t004

Early Referrals

The group of ER + NP patients showed markedly lower indicators of quality care than ER+P patients as well as less use of PD (p<0.05) [Table 4]. On the other hand, in a multivariate logistic regression analysis, the ER+P group was associated with eGFR >8.2 ml/min (OR 2.64, p = 0.001) and with information provided >2 months before initiation of dialysis (OR 38.5, p = 0.001). The final model was adjusted for age, gender, renal etiology and eGFR.

PD as RRT

PD was performed as first dialysis modality in 8.2% of patients (n = 45), with 5/45 as unplanned start. On the other hand, 14 NP patients who started with HD and a central venous line were switched to PD in the next six weeks reaching a final PD incidence of 59/547 (10.7%) (Table 5 and Fig 3).

thumbnail
Fig 3. Peritoneal dialysis (PD) incidence (%) according with different studied subgroups.

Maximum PD incidence was observed in the optimal care treated patients group being 22%. PD ranged 18% in the planned dialysis start, 16% in the early referred patients, 12% at modality information provision, 6% in the non-planned dialysis start, 5% in the late referral and no PD was observed if never previously informed. PD at the first dialysis session occurred in 8% and as first chronic RRT in 11% of the total studied population.

https://doi.org/10.1371/journal.pone.0155987.g003

PD incidence varied with age and patient subgroup (Fig 3). Patients who were not informed about RRT modalities never used PD. It is worthy to note that optimal care conditions had a big impact on the probability of PD as final RRT modality. Almost half of the PD patients (29/59, 49%) belonged to the optimal care patient group, whereas only 94/488 (19%) of HD patients did (p = 0.01).

Type of dialysis access (vascular or peritoneal)

Access at first dialysis session is described in Fig 2. Serum creatinine and CCr 24h at the time of access request were better in the P than in the NP group [4.9 (3.1–10) mg/dl; 14 (7.9–15.8) ml/min vs. 5.7 (3.1–11.1) mg/dl; 9.7 (5–18.9) ml/min], (p<0.001).]

Patients starting (n = 316) with a temporal vascular catheter were progressively switched in the next six weeks to a different access: 49% into an AVF, 36% permanent vascular catheter, 5% with a peritoneal catheter and no grafts use.

Discussion

In our multicenter, international experience most patients had medical follow ups since diagnoses of kidney disease. Almost half of the CKD care was provided by nephrologists. However, 49% of patients were referred late to our ICS clinics and 58% started dialysis in a NP manner, without a permanent dialysis access and/or in an emergency situation, most likely increasing morbidity, mortality and the cost of RRT [21,3031]. To our knowledge, this is the first evaluation of type of referral, dialysis start and modality choice on RRT described in Eastern Europe.

Over the past several years, interest has evolved in evaluating the timing of nephrology referral in the predialytic stage of CKD as an important variable related to prognosis. Late referral to predialysis care and its quality may influence the selection of dialysis modality as well as the timing and planning of dialysis start [19,23,3034]. The definition of the time factor “late” is somewhat arbitrary and varies in the literature, ranging from less than 1 month to less than 6 months follow-up before RRT is started.

Early referral to ICS was defined as at least a 3-month follow-up within the clinics’ care before starting RRT. However, at least one year is usually required to educate and optimize the preparation for RRT [13,3234]. There are wide differences between different centers and countries in late referrals [3536]. In Spain, Italy and France, data show that 20–25% of patients experienced late referrals, while higher figures are reported for other countries [3642]. The relatively low involvement of nephrologists since initiation of CKD follow-up (48%) compared with other series [23] may partially explain the high level of late referral. Late referral may deprive the patient from treatment to prevent or delay CKD progression and access to kidney transplantation, and inevitably lowers the possibility of receiving education, as well as choice options [11,32,43].

Numerous factors may be involved in a NP start, although some are unpredictable and others unacceptable/undesirable: asymptomatic renal disease (unpredictable), inadequate diagnosis or treatment of CKD (unacceptable), unexpected rapid deterioration of renal function, socio-economic reasons, patients reluctant to initiate dialysis or whose physicians underestimate the potential benefits of dialysis, long waiting lists to attend a predialysis care unit (unacceptable), waiting list for performing vascular access (unacceptable or undesirable) and others [23,4144]. To our knowledge only one earlier study has covered the real reasons behind an unplanned start especially in those patients previously followed by nephrologists [44]. In our study, patient-related reasons accounted for almost half of the causes behind a NP start.

It is striking that 21% of patients with NP start were previously followed-up for at least 3 months in our ICS clinics, but this period was considered insufficient to assure proper medical and emotional management and support, underlying a need to improve logistics at the time of referral. The high prevalence of late referred patients impacts the type of dialysis start and therefore the selection of dialysis modality. The large penetration of HD is higher for late referred patients and/or without previous follow-up. The fact that more patients who received information had a P start underlies the importance of patient empowerment for better control of risk factors, fluid overload and treatment compliance [33].

Our data indicate that there is an opportunity for improvement, as only 23% of patients had optimal care considered as followed-up at ICS clinics by nephrologists for >1 year, educated on dialysis modalities and with a planned dialysis start. Similarly to other series, choice of PD is more frequent with optimal care, confirming that PD patients are generally better informed, more conscious of their disease, know more about other RRT modalities and are more prone to recommend their therapy to other patients or even be more actively laboring [4546].

It is also remarkable that modality information and renal education were widely provided regardless of late referral and NP dialysis start, and that a large group of patients signed consents as information was provided and at dialysis start in accordance with recent international regulations [4748]. Nevertheless, the completeness and balance of information may have been overestimated, as clinics were free in the way they were delivering information and/or education to patients. This may be considered a limitation of the study. Proper information provision should have covered a structured process based in decision-making aids guidelines [4950]. A well-balanced presentation of all therapeutic options is usually associated with a higher selection of PD as first therapy [19,21,23,34,50] and, indeed, up to 50% of patients without medical contraindications for PD or HD selected PD [34,5154]. Patients with no previous PD information could not choose PD. Thus, we may expect higher rates of PD in the near future after increasing the number of specialized predialysis care staff at our clinics and streamlining the choice process [12,21,34,5051]. In this regard, we are planning to assess the impact of implementing the routine use of “decision-making aids” from 2014 [55].

Most authors have described better outcomes, longer survival, higher proportion of planned dialysis start and more PD choice for patients switched into specialized predialysis programs than if followed-up by a general nephrologist [23,50,56]. In this regard, we did not observe significant differences in terms of PD take on, probably related with the low number of clinics staffed by a specialized predialysis nephrologist and nurse during 2012. The shortage of nephrologists that some of these countries face does not permit a universal predialysis care specialization.

Conclusions

Although patients were frequently followed-up from the time of CKD diagnosis, referral patterns to ICS clinics have not been fully successful in Eastern Europe. Unplanned start was frequent and may explain the low frequency of PD. Despite the high rate of late referral, information and education were widely provided but probably not consistently structured and not long enough in duration due to the late referral. Measures such as implementation of referral patterns, reinforcement of predialysis staff specialization and routine use of decision-making aids may facilitate optimal care, improving well-being and planning of RRT start as well as increased PD use.

Acknowledgments

Alberto Ortiz for critically reading and commenting on the draft version of the manuscript.

Helen de la Maza edited the manuscript for English usage.

The following authors were part of the consortium d.PD Clinics Eastern Europe and were led by Belén Marrón: belen.marron@diaverum.com

Belén Marrón1, Diaverum Home Therapies. Medical Office, Munich, Germany.

Janusz Ostrowski2, Jaroslaw Kącki2, Pawel Kochman2, Roman Papis2 and Tomasz Jankowski2, Wloclawek Diaverum Clinic, Wloclawek, Poland.

Marietta Török3, Szeged Diaverum Clinic, Szeged, Hungary.

Delia Timofte4, Lacramiora Medrihan4, Andina Manditá4 and Monica Nitu4, Semaparc Diaverum Clinic, Bucharest, Romania.

Attila Orosz5 and Erzsebet Németh5, Bajcsy Diaverum Clinic, Budapest, Hungary.

Andrzej Kosicki6, Przemysl Diaverum Clinic, Przemysl, Poland.

Alicja Całka7 and Marcin Sarna7, Olsztyn Diaverum Clinic, Olsztyn, Poland.

Daniela Moro8 and Ioan Boca8, Sibiu Distributei Diaverum Clinic, Sibiu, Romania.

Dezider Kósa9, Zalaegerszeg Diaverum Clinic, Zalaegerszeg, Hungary.

Jenö Redl10 and M. Mester-Szabo10, Szolnok Diaverum Clinic, Szolnok, Hungary.

Catalin Tacu13, Industriilor Diaverum Clinic, Bucharest, Romania.

Waldemar Ślizień14 and Klaudiusz Wojnarowski14, Gdynia Diaverum Clinic, Gdynia, Poland.

Marcin Drobisz15 and Piotr Strzelczyk15, Katowice Diaverum Clinic, Katowice, Poland.

Krzysztof Doskocz16, Nysa Diaverum Clinic, Nysa, Poland.

Anna Bednarek-Skublevska17, Lublin Diaverum Clinic, Lublin, Poland and Department of Nephrology, the Medical University in Lublin, Poland

Raluca Mocanu18, Roman Diaverum Clinic, Roman, Romania.

Magyar Katalin19, Baja Diaverum Clinic, Baja, Hungary.

Julita Śliwarska20 and Malgorzata Gabrowska20, Starogard Diaverum Clinic, Starogard, Poland.

Rodica Illies21, Bistrita Diaverum Clinic, Bistrita, Romania.

Lidia Florescu22, Targu Jiu Diaverum Clinic, Targu Jiu, Romania.

Eniko Bodurian23, Odorheiu Secuiesc Diaverum Clinic, Odorheiu, Romania.

Eugenia Railean24, Medias Diaverum Clinic, Medias, Romania.

Ildiko Császár25, Hódmezővásárhely Diaverum Clinic, Hódmezővásárhely, Hungary.

Erzsébet Varga26, Kalocsa Diaverum Clinic, Kalocsa, Hungary.

Cristina Teodoru27 and Elena Agapi27, Sibiu Morilor Diaverum Clinic, Sibiu, Romania.

Magdalena Birecka28, Warszawa Białobrzeska Diaverum Clinic, Warsaw, Poland.

Author Contributions

Conceived and designed the experiments: BM JCDF. Performed the experiments: JO MT DT AO AK AC DM DK JR. Analyzed the data: BM ARQ JCDF. Contributed reagents/materials/analysis tools: BM JO MT DT AO AK AC DM DK JR ARQ JCDF. Wrote the paper: BM ARQ JCDF. Coordination at Poland: JO. Coordination at Romania: DT. Coordination at Hungary: MT. Global coordination: BM. Study monitoring: BM.

References

  1. 1. Zhang L, Wang F, Wang L, Wang W, Liu B, Liu J, et al. Prevalence of chronic kidney disease in China: a cross-sectional survey. Lancet 2012 Mar 3: 379 (9818): 815–22. pmid:22386035
  2. 2. Nugent RA, Fathima SF, Feigl AB, Chyung D. The burden of chronic kidney disease on developing nations: a 21st century challenge in global health. Nephron Clin Pract. 2011;118(3): c269–77. pmid:21212690
  3. 3. Gayoso-Diz P, Otero-González A, Rodríguez-Álvarez MX, García F, González-Quintela A, Martin de Francisco A. Strategy to estimate risk progression of chronic kidney disease, cardiovascular risk, and referral to nephrology: the EPIRCE Study. Nefrologia. 2013;33(2): 223–30. pmid:23511758
  4. 4. Levey AS, Andreoli SP, DuBose T, Provenzano R, Collins AJ. Chronic kidney disease: common, harmful and treatable—World Kidney Day 2007. Am J Nephrol 2007; 27: 108–112. pmid:17308371
  5. 5. Stewart JH, McCredie MR, Williams SM; Canadian Organ Replacement Register, Fenton SS, Trpeski L; Australia and New Zealand Dialysis and Transplant Registry, McDonald SP; European Renal Association-European Dialysis and Transplant Association Registry, Jager KJ, van Dijk PC; Finnish Registry for Kidney Diseases, Finne P; Swedish Registry for Active Treatment of Uremia, Schon S; Norwegian Renal Registry, Leivestad T; Danish National Registry on Regular Dialysis and Transplantation, Løkkegaard H; Dutch-speaking Belgian Society of Nephrology, Billiouw JM; Austrian Dialysis and Transplant Registry, Kramar R; Basque Renal Patients' Registry, Magaz A; Catalan Renal Registry, Vela E; Valencian Renal Registry, Garcia-Blasco MJ; Hellenic Renal Registry, Ioannidis GA; Malaysian National Renal Registry, Lim YN. The enigma of hypertensive ESRD: observations on incidence and trends in 18 European, Canadian, and Asian-Pacific populations, 1998 to 2002. Am J Kidney Dis 2006; 48: 183–190. pmid:16860183
  6. 6. Górriz JL M. Castelao A, De Alvaro F, Cases A, Portolés J, Luño J, et al. On Behalf of the MERENA and GEENDIAB Study Group. Morbidity and mortality factors in chronic kidney disease: diabetic and non-diabetic patients (MERENA Study). Baseline data. Nephrol. Dial. Transplant. 2005; 20 (Suppl 5): v17.
  7. 7. Villa G, Fernández-Ortiz L, Cuervo J, Rebollo P, Selgas R, González T, et al. Cost-effectiveness analysis of the Spanish renal replacement therapy program. Perit Dial Int. 2012 Mar-Apr;32(2): 192–9. pmid:21965620
  8. 8. De Vecchi AF, Dratwa M, Wiedemann ME. Healthcare systems and end-stage renal disease (ESRD) therapies—an international review: costs and reimbursement/funding of ESRD therapies. Nephrol Dial Transplant 1999; 14 Suppl 6: 31–41. pmid:10528710
  9. 9. Ramos R, Molina M. New models of integrated health care management in nephrology. Nefrologia. 2013;33(3): 301–7. pmid:23712220
  10. 10. Golper TA. The possible impact of the US prospective payment system ("bundle") on the growth of peritoneal dialysis. Perit Dial Int. 2013 Nov-Dec;33(6): 596–9. pmid:24335120
  11. 11. Orte L, Barril G. Advanced Chronic Kidney disease care unit. Concept of multidisciplinary care. Aims at the outpatient clinic of ESRD (Spanish). Nefrologia 2008; sup 3: 49–52
  12. 12. Ravani P, Marinangeli G, Stacchiotti L, Malberti F. Structured pre-dialysis programs: more than just timely referral?. J Nephrol 2003; 16: 862–869. pmid:14736014
  13. 13. Marrón B, Craver L, Ramón C, Prieto M, Gutierrez JM, Ortiz A: 'Reality and desire' in the care of advanced chronic kidney disease. NDT Plus 2010; 3: 431–435. pmid:25984045
  14. 14. Van Biesen W, Vanholder RC, Veys N, Dhondt A, Lameire NH. An evaluation of an integrative care approach for end-stage renal disease patients. J Am Soc Nephrol. 2000; 11: 116–25. pmid:10616847
  15. 15. Korevaar JC, Feith GW, Dekker FW, van Manen JG, Boeschoten EW, Bossuyt PMM, et al. Effect of Starting with Hemodialysis Compared with Peritoneal Dialysis in Patients New on Dialysis Treatment: A Randomized Controlled Trial. Kidney Int 2003; 64: 2222–2228. pmid:14633146
  16. 16. Lameire N, Van Biesen W. Doubts on the long term survival of peritoneal dialysis patients are no longer a medical barrier to home dialysis. At “Peritoneal Dialysis–State of the Art 2012”. Contrib Nephrol Basel, Karger, 2012; 178: 47–52. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/22652715 on September 28, 2015.
  17. 17. Heaf J. Underutilization of peritoneal dialysis. JAMA. 2004; 291: 740–2. pmid:14871920
  18. 18. Wu IW, Wang SY, Hsu KH, Lee CC, Sun CY, Tsai CJ, et al. Multidisciplinary predialysis education decreases the incidence of dialysis and reduces mortality—a controlled cohort study based on the NKF/DOQI guidelines. Nephrol Dial Transplant 2009; 24: 3426–3433. pmid:19491379
  19. 19. Marrón B, Martínez Ocaña JC, Salgueira M, Barril G, Lamas JM, Martin M, et al. Patient Flow Analysis into dialysis: role of education on dialysis modalities. Perit Dial Int. 2005; 25 Sup 3: S56–S59.
  20. 20. Curtis BM, Ravani P, Malberti F, Kennett F, Taylor PA, Djurdjev O, et al. The short- and long-term impact of multi-disciplinary clinics in addition to standard nephrology care on patient outcomes. Nephrol Dial Transplant. 2005; 20: 147–54. pmid:15585514
  21. 21. Ravani P, Marinangeli G, Tancredi M, Malberti F. Multidisciplinary chronic kidney disease management improves survival on dialysis. J Nephrol 2003;16: 870–7. pmid:14736015
  22. 22. Levin A. The need for optimal and coordinated management of CKD. Kidney Int Suppl 2005;99: s7–s10. pmid:16336580
  23. 23. Marrón B, Ortiz A, Sequera P,Martín-Reyes G, de Arriba G, Lamas JM, et al. Impact of end- stage renal disease care in planed dialysis start and type of renal replacement therapy—a Spanish multicentre experience. Nephrol Dial Transplant. 2006; 21 Suppl 2: 51–5.
  24. 24. Levin A, Lewis M, Mortiboy P, Faber S, Hare I, Porter EC, et al. Multidisciplinary predialysis programs: quantification and limitations of their impact on patient outcomes in two Canadian settings. Am J Kidney Dis, 1997; 29: 533–40. pmid:9100041
  25. 25. Cerqueira DC, Soares CM, Silva VR, Magalhaes JO, Barcelos IP, Duarte MG, et al. A predictive model of progression of CKD to ESRD in a predialysis pediatric interdisciplinary program. Clin J Am Soc Nephrol 2014; 9 (4): 728–35. pmid:24458086
  26. 26. Baer G, Lameire N., Van Biesen W. Late referral of patients with end-stage renal disease: an in-depth review and suggestions for further actions. NDT Plus 2010; 3: 17–27. pmid:25949401
  27. 27. Gorriz JL, Sancho A, Pallardo LM, Amoedo ML, Barril G, Salgueira M, et al. Longer pre-dialysis nephrological care is associated with improved long-term survival of dialysis patients. More facts. Nephrol Dial Transplant 2002; 17: 1354–1355. pmid:12105266
  28. 28. Goovaerts T, Bagnis Isnard C, Crepaldi C, Dean J, Melander S, Mooney A, et al. Continuing education: preparing patients to choose a renal replacement therapy. J Ren Care. 2015 Mar;41(1):62–75. pmid:25597792
  29. 29. Bardon E, Marti A, Vila ML. Nursing in advanced CKD clinic. Nefrología 2008; sup 3: 53–56 32.
  30. 30. Gorriz JL, Sancho A, Pallardo LM, Amoedo ML, Martin M, Sanz P, et al. Prognostic significance of programmed dialysis in patients who initiate renal substitutive treatment. Multicenter study in Spain. Nefrologia 2002, 22: 49–59. pmid:11987685
  31. 31. Lorenzo V, Martín M, Rufino M, Hernández D, Torres A, Ayús JC. Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: an observational cohort study. Am J Kidney Diseases 2004; 43: 999–1007.
  32. 32. Covic A, Bammens B, Lobbedez T, Segall L, Heimburger O, Van Biesen W, et al. Educating end-stage renal disease patients on dialysis modality selection: clinical advice from the European Renal Best Practice (ERBP) Advisory Board. Nephrol Dial Transplant 2010; 25:1757–1759. pmid:20392704
  33. 33. Van Biesen W, Verbeke F, Vanholder R. We don´t need no education….(Pink Floyd, The Wall) Multidisciplinary predialysis education programmes: pass or fail? Nephrol Dial Transplant. 2009; 24: 3277–3279. pmid:19736244
  34. 34. Hughes SA, Mendelssohn JG, Tobe SW, McFarlane PA, Mendelssohn DC. Factors associated with suboptimal initiation of dialysis despite early nephrologist referral. Nephrol Dial Transplant 2013; 28: 392–397. pmid:23222418
  35. 35. Korevaar JC, Feith GW, Dekker FW, Van Manen JG, Boeschoten EW, Bossuyt PMM, et al. Effect of Starting with Hemodialysis Compared with Peritoneal Dialysis in Patients New on Dialysis Treatment: A Randomized Controlled Trial. Kidney Int 2003; 64: 2222–2228 pmid:14633146
  36. 36. Smart NA, Dieberg G, Ladhani M, Titus T. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease. Cochrane Database Syst Rev 2014, 6: Cd007333. pmid:24938824
  37. 37. Mendelssohn DC, Malmberg C, Hamandi B. An integrated review of "unplanned" dialysis initiation: reframing the terminology to "suboptimal" initiation. BMC Nephrol. 2009; 10: 22–30. pmid:19674452
  38. 38. Yu YJ, Wu IW, Huang CY, Hsu KH, Lee CC, Sun CY, et al. Multidisciplinary predialysis education reduced the inpatient and total medical costs of the first 6 months of dialysis in incident hemodialysis patients. PLoS One. 2014 Nov 14;9(11): e112820. pmid:25398129
  39. 39. Sprangers B, Evenepoel P, Vanrenterghem Y. Late referral of patients with chronic kidney disease: No time to waste. Mayo Clin Proc 2006; 81:1487–1494. pmid:17120405
  40. 40. Heatley SA. Optimal referral is early referral. Perit Dial Int 2009; 29 Suppl 2: S128–131. pmid:19270201
  41. 41. Karkar A. The value of care. Saudi J Kidney Dis Transpl 2011; 22: 419–427. pmid:21566294
  42. 42. Navaneethan SD, Aloudat S, Singh S. A systematic review of patient and health system characteristics associated with late referral in chronic kidney disease. BMC Nephrol 2008; 9:3. pmid:18298850
  43. 43. Cass A, Cunningham J, Snelling P, Ayanian JZ. Late referral to a nephrologist reduces access to renal transplantation. Am J Kidney Dis. 2003;42: 1043–9. pmid:14582048
  44. 44. Buck J, Baker R, Cannaby AM, Nicholson S, Peters J, Warwick G. Why do patients known to renal services, still undergo urgent dialysis initiation? A cross-sectional survey. Nephrol Dial Transplant 2007; 22: 3240–5. pmid:17616535
  45. 45. Rubin HR, Fink NE, Plantinga LC, Sadler JH, Kliger AS, Powe NR. Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. JAMA. 2004; 291: 697–703. pmid:14871912
  46. 46. Julian-Mauro JC, Cuervo J, Rebollo P, Callejo D. Employment status and indirect costs in patients with renal failure: differences between different modalities of renal replacement therapy. Nefrologia 2013; 33: 333–341. pmid:23712223
  47. 47. Kainer G, Fetherstonhaugh D. The CARI guidelines. Ethical considerations. Nephrology 2010; 15 Suppl 1: S12–4. Available at: www.ncbi.nlm.nih.gov/pubmed/20591023 on September 28, 2015. pmid:20591023
  48. 48. Ley 41/2002 del 14 de Noviembre del 2002: Básica reguladora de la autonomía del paciente y de derechos y obligaciones en materia de información y documentación clínica. BOE N° 279: 40126–40132.
  49. 49. Barry MJ, Edgman-Levitan S. Shared decision making-pinnacle of patient-centered care. N Engl J Med 2012; 366: 780–781. pmid:22375967
  50. 50. Isnard Bagnis C, Crepaldi C, Dean J, Goovaerts T, Melander S, Nilsson EL, et al. Quality standards for predialysis education: results from a consensus conference. Nephrol Dial Transplant. 2015 Jul; 30 (7): 1058–66. pmid:24957808
  51. 51. Prieto-Velasco M, Isnard Bagnis C, Dean J, Goovaerts T, Melander S, Mooney A, et al. Predialysis education in practice: a questionnaire survey of centres with established programmes. BMC Res Notes. 2014 Oct 17; 7: 730. pmid:25326141
  52. 52. Hanko J, Jastrzebski J, Nieva C, White L, Li G, Zalunardo N. Dedication of a nurse to educating suboptimal haemodialysis starts improved transition to independent modalities of renal replacement therapy. Nephrol Dial Transplant. 2011 Jul; 26(7): 2302–8. pmid:21071546
  53. 53. Prichard SS. Treatment modality selection in 150 consecutive patients starting ESRD therapy. Perit Dial Int 1996; 16: 69–72. pmid:8616177
  54. 54. Prieto-Velasco M, Quiros P, Remon C; Spanish Group for the Implementation of a Shared Decision Making Process for RRT Choice with Patient Decision Aid Tools. The Concordance between Patients' Renal Replacement Therapy Choice and Definitive Modality: Is It a Utopia?. PLoS One. 2015 Oct 14;10(10):e0138811. Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0138811 pmid:26466387
  55. 55. Marrón B, Ostrowski J, Timofte D, Török M, Kochman P, Orosz A, et al. Impact of decision making tools use at the time of modality choice and PD take on in a multicenter-multinational setting. At 12th European Peritoneal Dialysis Meeting Krakow, Poland 2015 and ASN Kidney Week, San Diego 2015 (Abstract).
  56. 56. Gutiérrez Vilaplana JM, Zampieron A, Craver L, Buja A. Evaluation of psychological outcomes following the intervention 'teaching group': study on predialysis patients. J Ren Care. 2009 Sep; 35(3): 159–64. pmid:19689699